“If the Soldier Dies, It’s on You”

Summary

People who have nothing to do with the war are dying. Health professionals are targeted, tortured, arrested, killed. We want to be free to give treatment to whoever needs it.

- Medical Doctor, South Gonder Zone, Amhara region, Ethiopia, January 2024

Solomon was a medical doctor in a town in West Gojjam Zone in Ethiopia's northwestern Amhara region when armed conflict broke out in August 2023 between the Ethiopian federal government and an Amhara militia known as Fano.

Like many other medical professionals working in towns experiencing heavy fighting, he focused on treating all categories of patients, including those wounded in the fighting and those with non-trauma needs, despite the hospital's decreasing resources and the very real risks health workers faced, including attacks from warring parties.

By early November 2023, the Ethiopian military had taken control of the town. Soldiers seized the hospital's ambulance, accusing doctors of using it to provide treatment to Fano fighters. They also began regularly harassing staff, including Solomon, threatening them and repeatedly searching the hospital as well as the residences of hospital staff. Despite this, he and his colleagues continued to treat patients. In December, Solomon began receiving threatening phone calls from unknown callers whom he believed were government soldiers, questioning his relationship with Fano. He later found out the military had placed his name on a list of individuals suspected of giving treatment to Fano fighters. Fearing for his life, he fled the town, adding to the growing number of healthcare professionals who have stopped medical practice in the region or relocated beyond the front lines.

Many doctors, nurses and other health workers in the Amhara region have had similar experiences. For the past three years, since the start of northern Ethiopia's armed conflict in November 2020, both Ethiopian government forces and non-state armed groups have repeatedly targeted medical professionals, others in the health sector as well as medical facilities.

This report documents the devastation of the healthcare system in 13 towns in the Awi, North Gojjam, West Gojjam, North Gonder, South Gonder, and South Wollo Zones of Amhara since the onset of conflict in region's in August 2023. Human Rights Watch found that the Ethiopian military has committed serious violations of international humanitarian law-the laws of war-which may amount to war crimes.

Government security forces, including Ethiopian military, police and militia, have killed health workers and patients, threatened and assaulted doctors, wrongfully arrested patients, looted and destroyed medical supplies, and misused healthcare facilities. They have targeted ambulances, including in at least one apparent drone strike. They have repeatedly raided hospitals in search of patients with injuries, in particular gunshot, blast or fragmentation wounds, which the military considers to be proof of participating in fighting or having Fano-fighter affiliation.

Such actions severely hamper access to health care in Amhara. "There are many injured people due to the fighting, but … they can't get service at the hospital ... because if the government sees a person injured with bullet or weapon, they consider them Fano," said a doctor in a South Gonder Zone hospital. "So, people injured in rural areas, or even in towns, won't go to the hospital."

This report draws on 58 remote interviews carried out between August 2023 and May 2024 with victims and witnesses to abuses, health professionals, and aid workers. Human Rights Watch also analyzed satellite imagery and verified videos and photographs posted online and sent directly to researchers following an apparent drone attack on an ambulance. Previous research and interviews carried out in 2021 and 2022 on the destruction and looting of healthcare facilities in Amhara by Tigrayan forces in North and South Wollo Zones during the 2020-2022 conflict in northern Ethiopia, provided further context.

While the immediate trigger of the conflict in Amhara was the federal government's decision in April 2023 to dissolve the country's regional special forces, locally known as "Liyu Hail," and integrate them into the military, federal police, or regional police forces, grievances against the federal government in the region have been brewing for at least four years. The April 2023 announcement caused sporadic clashes between government security forces and protesters and Fano-an Amhara militia distinct from the region's government-affiliated militia-that in months evolved into armed conflict.

August 2023 marked a tipping point. Fano forces took control of several cities and towns in the region. Ethiopian authorities responded with a heavy hand, imposing a sweeping state of emergency on the region and mobilizing the military, Amhara regional police, and government-affiliated militias to fight against Fano forces.

Since then, communities in Amhara have borne the brunt of the fighting between Ethiopian government forces and Fano. Control of various towns has remained tenuous, particularly in West Gojjam, East Gojjam, South Gonder, and North Shewa, and South Wollo Zones, with government forces and Fano fighters clashing in towns, blocking roads to gain an upper hand, and showing little regard for protecting the civilian population. Civilians have been killed or injured in their homes, on hospital grounds, and in public and medical transport.

The fighting has also disrupted the delivery of medical supplies, leading hospitals and healthcare centers to face acute and prolonged shortages of essential medicines and other necessary healthcare goods. Doctors seeking to replenish depleted hospital supplies have aroused the suspicion of government forces and in some cases have come under attack, affecting their ability to provide care to patients in a safe environment. Humanitarian aid agencies working to fill gaps in medical supplies and equipment have also faced an increasingly challenging operating environment since August 2023 due to ongoing fighting, towns frequently changing control, and movement restrictions, including difficulty moving to Fano-controlled areas. Aid agencies are now forced to rely on expensive air travel to supply a small fraction of the healthcare goods the population needs.

The breakdown of administrative structures due to fighting in some areas has also prevented funds from reaching healthcare providers, contributing to shortages of essential medicines and medical equipment. Amhara residents who previously relied on the government's community-based health insurance program have been instead left with the choice of buying expensive medications from private pharmacies or forgoing treatment altogether. Belete, a medical professional, described the challenges: "Nothing is operational, the x-rays are no longer working, we don't have medicine, we don't have a budget. No government agency is operational, the government health insurance is not working to get the treatment they need. It is a disaster."

Ethiopia is a party to the International Covenant on Economic, Social and Cultural Rights (ICESCR), which recognizes the right of everyone to the highest attainable standard of health. Governments remain obligated to ensure minimum essential levels of the right to health even during armed conflict, including ensuring the non-discriminatory distribution of and access to health facilities, goods and services and providing essential medicines.

The United Nations, human rights groups and the media have reported on security force abuses in Amhara, including unlawful attacks on civilians, summary killings, and mass arrests without due process. Yet, few of Ethiopia's regional and international partner countries have responded or weighed in on the situation, despite the urgency of the human rights and humanitarian crisis in Amhara and the country more broadly. Since the Ethiopian federal government and Tigrayan authorities signed a cessation of hostilities agreement in November 2022, ending the devastating two-year armed conflict that took hundreds of thousands of lives amid widespread atrocities, the limited efforts to promote accountability and end abuses have dissipated.

The failure of the UN Human Rights Council to renew the mandate of the International Commission of Human Rights Experts on Ethiopia (ICHREE) in October 2023, further foreclosed options for international scrutiny and independent investigations into the country's human rights situation. Since then, Ethiopian authorities have taken no meaningful steps to hold abusive federal and regional forces to account, emboldening abusive commanders in the ongoing fighting in Amhara.

Human Rights Watch urges the federal forces and Fano fighters to abide by their international law obligations. This includes ending attacks on and the endangerment of hospitals and other healthcare centers in Amhara, permitting medical professionals and health workers to safely provide treatment to civilian and military patients, and ensure medical supplies and humanitarian aid reaches medical facilities.

International and regional bodies, notably the African Union and European Union, and concerned governments should immediately urge resumed scrutiny of the human rights situation in Ethiopia. They should encourage the UN High Commissioner for Human Rights to publicly report on abuses in Amhara and other conflict-affected areas in the country. The United Nations and the African Union should suspend any new deployments of Ethiopian soldiers into peacekeeping missions pending an independent assessment of their participation in abuses and compliance with international law.

Glossary

APHI - Amhara Public Health Institute

CBHI - Community Based Health Insurance

EHRC - Ethiopian Human Rights Commission

ENDF - Ethiopian National Defense Forces

EPSA - Ethiopian Pharmaceutical Supply Agency

ETB - Ethiopian Birr, calculated at 1 equal's approximately 0.017 US dollars as of April 2024

Fano - Non-state Amhara militia

ICHREE - International Commission of Human Rights Experts on Ethiopia

ICRC - International Committee of the Red Cross

Kebele - "Neighborhood" in Amharic and the smallest administrative subdivision at the neighborhood level

Militia - Armed community security that are not part of the regional security forces, but which have played a role in Ethiopia's internal security at the local, community level

OCHA - United Nations Office for the Coordination of Humanitarian Affairs

OHCHR - United Nations Office of the High Commissioner for Human Rights

Prosperity Party - Ethiopia's ruling political party, which was established on December 1, 2019

UN - United Nations

Woreda - District level administrative unit

Key Recommendations

To all parties to the conflict

• Abide by international humanitarian law. Issue clear public orders to all forces to end attacks on and ensure the protection of medical facilities, healthcare workers, patients, and ambulances.

To the Ethiopian Federal Government

• Strengthen the legal framework to protect health staff, including by passing specific legislation that protects healthcare workers and medical professionals and attacks on healthcare facilities.

To the Ministry of Health

• Take all necessary steps to end the healthcare crisis in the Amhara region, including through allocating resources to ensure that public healthcare facilities in the region and in other conflict-affected areas have adequate equipment, supplies, and staff to ensure the highest possible quality of care.

To Ethiopia's Donors, and International Partners

• Publicly condemn harassment and attacks against healthcare in the Amhara region and other conflict-affected areas.

• Press warring parties to remove all restrictions that impede or delay communities' access to health care and humanitarian aid and enhance the protection of and access to health care in situations of armed conflict as set out in the Secretary-General's recommendations to the Security Council in 2016 and UN Security Council resolution 2286 on attacks against healthcare facilities in conflict.

• Increase support to independent nongovernmental organizations providing healthcare services in the region.

• Call for accountability for abuses and seek, greater attention from multilateral forums on the human rights situation in Ethiopia.

  Methodology

This report is based on research Human Rights Watch carried out between August 2023 and May 2024. Human Rights Watch interviewed 52 residents and healthcare workers in Ethiopia's Amhara region by phone who have been severely affected by the conflict in the Amhara region between August 2023 and January 2024, as well as six aid workers. Previous research and interviews carried out with nine people in 2021 and 2022 on the destruction and looting of healthcare facilities in Amhara by Tigrayan forces in North and South Wollo Zones during the conflict in northern Ethiopia, provided additional background and context. Human Rights Watch also reviewed satellite imagery, and verified videos and photographs found online and sent directly to researchers in the aftermath of an apparent drone strike on an ambulance in South Wollo Zone.

The report documents specific incidents and trends affecting civilians access to health care at hospitals and health centers in 13 towns in the Awi, North Gojjam, West Gojjam, North Gonder, South Gonder, and South Wollo Zones. This is not a comprehensive survey of all violations that have taken place in the region since the conflict intensified and does not cover abuses by Fano militia against communities in the region.

Interviews were conducted remotely and focused on attacks on health care in the region and the broader impact of the fighting on communities and the healthcare system in the region. Interviews were conducted in Amharic or English, at times with the help of a trusted interpreter.

Human Rights Watch informed all interviewees of the nature and purpose of our research. We informed each potential interviewee that they were under no obligation to speak to us, that Human Rights Watch does not provide legal or other assistance, and that they could end the interview at any time or decline to answer any question without consequence. We obtained oral consent for each interview, and interviewees did not receive material compensation for speaking with Human Rights Watch.

Many interviewees feared repercussions if their names were revealed and requested anonymity. For this reason, names and other identifying details have been withheld to protect interviewees' security, and in the footnotes to this report, all interviewees, unless otherwise noted, have been assigned pseudonyms. In some cases, the location of interviewees has also been withheld to avoid endangering them. In some cases, the location in which the events described took place has also been withheld for the same reason.

Background

On April 6, 2023, the Ethiopian federal government announced its plans to dissolve the country's regional special forces, or "Liyu Hail," as it is locally known in Amharic, the working language of the federal government, and integrate its members into the military, federal police, or regional police forces. The government said that the regional special forces were a risk to Ethiopia's unity and a source of competition and show of force among the country's states.^[1]

Ethiopia's constitution grants regions the autonomy to "establish and administer a state police force and to maintain public order and peace within the state." However, regional special police are not mentioned in any legal provision, allowing such forces to operate with a broad and ambiguous mandate and structure.^[2] Emerging first in the Somali region in 2007 in the context of abusive government counterinsurgency operations there, increasingly militarized regional special police forces have proliferated throughout Ethiopia in the last 15 years. Research by Human Rights Watch and other organizations have found these forces to have been responsible for serious human rights violations.^[3]

Response to Government Announcement

While the government's decision applied to regional special forces across the country, it severely exacerbated existing grievances against the federal government in the Amhara region, predominantly inhabited by ethnic Amhara, and provoked widespread protests and armed resistance in major cities and towns.^[4]

Within days of the announcement, demonstrators blocked roads and burned tires, while authorities shut down access to mobile internet services and imposed movement restrictions and a curfew to quell the unrest.^[5] Ethiopian federal security forces, including federal police and intelligence officers in the country's capital, Addis Ababa, as well as in the region, arrested journalists, most of whom had been reporting and providing commentary on political and social issues affecting ethnic Amhara.^[6] Amhara political opposition groups, such as the National Movement of Amhara (NAMA) party, quickly criticized the government's decision as inappropriate and hasty, and warned it would expose Amhara communities to attacks.^[7]

In early April, members of the Amhara special forces refused to comply with the government's order.^[8] They, together with armed, informal militia known as "Fano," directly clashed with the Ethiopian military, resulting in casualties on both sides.^[9]

On April 9, 2023, unidentified gunmen shot and killed two aid workers with Catholic Relief Services in the town of Kobo, in North Wollo Zone, as they travelled in the organization's vehicle.^[10] That same day, Ethiopian Prime Minister Abiy Ahmed asserted that the government's decision "will be implemented for the sake of multi-national unity of Ethiopia and the peace of its people by paying a sacrifice if need be. Appropriate law enforcement measures will be taken against those who deliberately play the role of distortion"^[11]

One week later, the army chief of staff announced that the government had completed its efforts in disbanding the regional special forces. Girma Yeshitila, the head of the Amhara branch of the country's ruling political party-the Prosperity Party-acknowledged that around 30 percent of the Amhara regional forces had abandoned their posts in the process.^[12]

On April 27, gunmen killed Girma Yeshitila as he was travelling with his family and bodyguards in the region, according to Amhara regional authorities.^[13] The following day, the joint security and intelligence task force-comprised of the National Intelligence and Security Services (NISS), the military, the Federal Police Commission, and Information Network Security Agency (INSA)-announced it was taking decisive measures against "extremist forces" that were trying to take control and destroy the constitutional system in the Amhara region.^[14]

Authorities began cracking down on individuals following Girma's assassination by engaging in roundups, primarily along ethnic lines, in the Amhara region, but also included the arrest of critical voices in Addis Ababa.^[15] The joint task force announced the detention of 47 "terror suspects" that it accused of working together in Ethiopia and in other countries to take administrative control of Amhara and overthrow the federal government by assassinating officials in the region.^[16] The list included individuals that the authorities had previously detained, including the journalist Gobeze Sisay, and Lidetu Ayalew, a political opposition figure residing in the United States.^[17]

Escalating Violence

The fragmented tactics of Fano fighters morphed into widespread attacks against local administrative structures. The national Ethiopian Human Rights Commission, a federal body established by the Ethiopian Constitution and accountable to parliament, reported on attacks on prisons and police stations and the killing of government officials.^[18] The authorities accused Fano fighters of the assassination of senior regional security officials, as well as attacking a federal army convoy.^[19]

In late July, fighting intensified in different parts of the region, with fighting breaking out in the region by early August when Fano attacked and controlled major towns and cities in the region, including Bahir Dar, the regional capital, Gonder, and Lalibela, prompting the Amhara regional president at the time, Yilikal Kefale to formally request the federal government to respond to the deteriorating security crisis and intervene by "implement[ing] the necessary legal framework."^[20]

On August 4, 2023, Ethiopia's Council of Ministers announced a six-month state of emergency, establishing a command post to coordinate the federal and regional security forces in the region led by Temesgen Tiruneh, the then head of the country's intelligence agency, the National Intelligence and Security Services (NISS).^[21] This placed the region under military rule. To enforce the state of emergency, four command posts were established in Amhara, comprising of the West Amhara, East Amhara, Northwest Amhara, and Central Shewa command post.

Temesgen acknowledged that armed groups operating in the region had taken control of districts and towns in the region, including government institutions, and broke into prisons and forcibly released prisoners.^[23] He confirmed that the command post would be comprised of Ethiopian military forces, federal police, and regional police. Residents in Amhara confirmed to Human Rights Watch that military forces would often be accompanied by Amhara regional anti-riot police as well as local government militias.^[24]

The state of emergency, which Ethiopia's parliament endorsed on August 14, contained sweeping restrictions that granted the government powers to arrest criminal suspects without a court order, impose curfews, ban public gatherings, and carry out searches without a warrant. The command post system also centralizes military, law enforcement, and civilian authority under one security structure. While currently limited to Amhara, the declaration could be extended to "any area of the country as necessary."^[25] Government authorities carried out mass arrests of predominantly ethnic Amhara in Addis Ababa, including Christian Tadele, an opposition member of parliament and outspoken critic of the ruling party and the government's actions in the Amhara region.^[26]

In September, the army chief of staff, Birhanu Jula, said that the situation in the region "no longer posed a security threat."^[27] Fighting at the time of writing is ongoing, however, with persistent clashes reported in different administrative zones in the region, particularly in North and West Gojjam Zones, South Gonder Zone, South Wollo Zone, and North Shewa.^[28]

On February 2, 2024, Ethiopia's parliament extended its six-month state of emergency in Amhara by an additional four months.^[29] On January 31, days before parliament voted to extend the state of emergency, Ethiopian security forces, including two members of the federal police, arrested Dessalegn Chanie, a member of parliament representing the opposition party, the National Movement of the Amhara (NAMA).^[30] Dessalegn was released on March 14.

The state of emergency expired in June 2024.

Since the start of the conflict, international and domestic human rights groups, as well as the media, have reported on abuses by Ethiopian forces, including the summary execution of civilians.^[32] The Ethiopian Human Rights Commission (EHRC) found civilians were killed in crossfire during heavy fighting between Fano and Ethiopian government forces in towns and cities in the region in August.^[33]

The Office of the United Nations High Commissioner for Human Rights (OHCHR) estimated that the fighting had killed 183 people in July and August 2023 alone. OHCHR also received reports of more than 1,000 people arrested under the state of emergency, with many of those detained reported to be ethnic Amhara suspected of supporting Fano.^[34] In June 2024, OHCHR released a report analyzing the human rights situation in Ethiopia between January 2023 and January 2024, and found government forces, notably the Ethiopian defense forces, Amhara regional police, and state-affiliated militia responsible for the majority of the 179 incidents documented, including "extrajudicial and arbitrary executions; rape/conflict-related sexual violence; heavy artillery against civilians; attacks on and destruction of civilian objects; attacks against medical personnel; attacks against religious sites; arbitrary arrests, torture or ill-treatment; and the use of schools for military purposes." The report also found Fano militia responsible for killings of civilians-mainly government officials-as well as attacks on and destruction of civilian objects; attacks against medical personnel; attacks against ambulances; and arbitrary arrests.

Amnesty International reported on Ethiopian soldiers' extrajudicial executions of six civilians, including a 54-year-old woman, in Bahir Dar on August 8, 2023.^[36] Human Rights Watch found that on January 29, 2024, Ethiopian military forces killed dozens of civilians in Merawi, marking one of the deadliest incidents since the outbreak of conflict in August 2023.^[37] Soldiers also pillaged and destroyed civilian property. On February 24, military forces killed civilians in Merawi following another attack by Fano fighters in the town.^[38]

Ethiopian authorities have increasingly made use of armed drones in the Amhara region.^[39] In November 2023, OHCHR reported on drone strikes hitting civilian infrastructure, including a school and a bus station, and killing civilians.^[40] OHCHR's June 2024 report found that the Ethiopian Airforce's use unmanned aerial vehicles (UAVs) resulted in 248 civilian deaths, and 55 injuries and the destruction of schools, hospitals, and private homes between August 4 and December 31, 2023. Armed groups have also looted homes, blocked roads and imposed "taxes" on civilians, and abducted people they suspect of supporting the government.

Impact of Conflict

The current conflict in Amhara has hindered the population's access to goods and services essential to their lives and livelihoods and exacerbated existing humanitarian crises.^[43] Prior to the uptick in fighting in June 2023, the region reportedly hosted 580,000 internally displaced people according to data from the Amhara regional government, in addition to hosting thousands of Eritrean refugees and the influx of refugees from Sudan since the outbreak of conflict there in April 2023.^[44]

In late 2023, regional authorities alerted aid agencies that over two million people were affected by drought and conflict in 43 districts of North and South Wello, North Shewa, Oromia Special and North Gondar zones and that one million people also lacked access to drinking water in drought-affected areas.^[45] In mid-July 2023, aid agencies reported on suspected cholera cases in nine administrative zones in Amhara, believed to have originated from religious water sites that attract Orthodox Christian followers in West Gonder Zone. The World Health Organization also described an increase in measles and malaria cases in Amhara in late 2023, though the lack of access for aid agencies and internet shutdown in the region hindered the process of carrying out crucial disease surveillance and intervention.^[47]

Prior to the current conflict, several healthcare facilities in the Amhara region, most notably in North and South Wollo Zones, were already overburdened and trying to recover in the aftermath of the conflict in northern Ethiopia. Between June and December 2021, Tigrayan forces occupied, looted and destroyed healthcare facilities in areas under their control.^[48] In September 2021, Ethiopia's Minister of Health, Dr. Lia Tadesse, stated that 20 hospitals and 277 health centers were nonfunctional in the Amhara region alone.^[49] Other public hospitals in the region, including Bahir Dar university referral hospital and Debre Tabor hospital provided medical treatment and support for wounded members of the Ethiopian military and Amhara regional special police forces in 2021 during the conflict in northern Ethiopia, which further burdened hospital budgets.^[50]

Following the cessation of hostilities in northern Ethiopia, donors and international financial institutions, such as the World Bank, have committed to rehabilitate damaged health facilities in conflict-affected areas, including in Amhara.^[51] For instance in 2022, Expertise France, a French public agency, began rehabilitating Dessie referral hospital, in South Wollo Zone. In 2023, France provided €3.5 million to support hospitals in Afar and Tigray regions. In March, Japan committed over US$1.8 million to support health and nutrition services, as well as rehabilitation efforts in northern Ethiopia. In April, the European Union approved a €25 million plan for the restoration of health services and to support survivors of gender-based violence, including in the Amhara region. That same month, United States, as Ethiopia's largest donor of humanitarian assistance, pledged an additional $154 million in new humanitarian assistance to Ethiopia, to support food security, health, protection, shelter, water, and sanitation. Continued hostilities in Amhara and other conflict-affected areas mean rehabilitation and reconstruction efforts will fall short and may not reach intended populations.

By early March 2024, Amhara regional health officials stated that the ongoing conflict in the region between government forces and Fano forces caused extensive damage to the healthcare system in the region, claiming that "extremist forces," pillaged 967 health facilities and seized 124 ambulances.^[57]

International Legal Standards

International Humanitarian Law, or Laws of War

Under international humanitarian law, or the laws of war, the ongoing hostilities between Ethiopian government forces and Fano militia in Amhara amounts to a non-international armed conflict.

There are three recognized requirements for a non-international armed conflict. First, there must be protracted violence or a sufficient degree of intensity in hostilities between the parties, measured by the weapons employed, duration, and other factors. Second, the violence must be conducted by government forces and one or more non-state armed groups, or between two or more non-state armed groups. Third, the armed groups must exhibit sufficient organization and control to be capable of sustaining military operations and adhering to international humanitarian law, so they could be considered "parties" to the conflict.

In Amhara, the criteria for a non-international armed conflict was met when fighting between the Ethiopian military and armed groups calling themselves "Fano," which began in April 2023, intensified by July when the Fano armed groups took control of major towns and cities in the Amhara region. Reports of repeated armed confrontations throughout the Amhara region using military weapons indicated that the fighting reached a sufficient degree of intensity to be considered an armed conflict. While Fano fighters in the Amhara region appear to lack a single unified command structure, Fano forces in different administrative structures have been operating under an identified command structure, have demonstrated a capacity to exercise control, and waged coordinated attacks on defined territories.

The non-international armed conflict in Amhara, between the Ethiopian military and Fano militias, is governed by international humanitarian law set out in treaties and in the rules of customary international law.

Common Article 3 to the four Geneva Conventions of 1949 sets out protections for civilians and combatants in custody. Ethiopia is also party to the Second Additional Protocol to the Geneva Conventions (Protocol II), which provides further protections for combatants and civilians during non-international armed conflicts.

In addition to providing protection from attack for civilians and civilian objects, the laws of war also set out special protections for hospitals and other medical facilities, healthcare personnel, and ambulances and other medical transportation. These protections apply to both military and civilian medical facilities. Warring parties may not attack medical facilities, deploy their forces in a manner that puts medical facilities at risk, or interfere with their functioning. Medical facilities remain protected unless they are used outside their humanitarian function to commit harmful acts to the enemy.

Parties to a conflict are prohibited from impairing access to medical treatment. The wounded and sick, including injured fighters, must not be denied medical care, and must be protected from ill-treatment and theft. No distinctions may be made among them except on medical grounds.^[59]

Under the laws of war, doctors, nurses and other medical personnel must be permitted to do their work and be protected in all circumstances.^[60] Treating wounded soldiers or fighters is part of the humanitarian function of a hospital and medical facilities may never be attacked for doing so.^[61]

Several types of acts do not constitute "acts harmful to the enemy," such as the presence of armed guards, or when small arms from the wounded are found in the hospital. Even if military forces misuse a hospital to store weapons or shelter able-bodied combatants, a warning must be issued giving a reasonable time limit and an attack may not proceed unless such a warning has gone unheeded.

Likewise, ambulances and other medical transport must be allowed to function and be protected in all circumstances. They lose their protection only if they are being used to commit acts harmful to the enemy, such as transporting ammunition or healthy fighters.^[62]

International Human Rights Law

During armed conflict, while international humanitarian law provisions may supersede international human rights law as the lex specialis ("specialized law"), human rights law remains in effect. The International Covenant on Economic, Social and Cultural Rights (ICESCR), to which Ethiopia is party, obligates states in article 12 to respect, protect, and fulfill the right to the highest attainable standard of physical and mental health.

The Committee on Economic, Social and Cultural Rights (CESCR), the international expert body that provides authoritative guidance on the ICESCR, elaborated in its General Comment No. 14 that states are required to comply with non-derogable, core obligations that represent the minimum essential levels of the right to health even in times of conflict. This includes the obligation to ensure the equitable distribution and access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalized groups, and the obligation to provide essential medicines.

The UN Office of the High Commissioner for Human Rights (OHCHR), in its Report on the Protection of Economic, Social and Cultural Rights in Conflict, states that in accordance with General Comment No. 14, even when conflicts result in resource constraints, governments are obligated under the ICESCR to ensure the availability, accessibility and acceptability of good quality health facilities, goods and services, especially for vulnerable groups. Violating the right to health during armed conflict can include: decimating the healthcare system; directly attacking medical personnel, facilities and transports, as well as the wounded and sick; obstructing access to health care; limiting access to health services as a punitive measure; and threatening or restricting access to the underlying determinants of health, such as safe and potable drinking water, adequate sanitation, housing and food.

In December 2014, the United Nations General Assembly passed a landmark resolution that urged governments to take immediate steps to ensure that health workers are protected from violence.^[67] In 2016, the UN Security Council passed resolution 2286 that called for greater protection for health care in armed conflict and affirmed that attacks against medical facilities and health workers in conflicts are war crimes.

The Ethiopian government is also under the non-derogable obligation not to subject any individuals under their jurisdiction or control to arbitrary deprivation of life, and they must respect, protect and fulfill the right to health of affected populations. The authorities' denial of medical assistance to injured persons violates both international humanitarian law and the rights to health and non-discrimination under international human rights law.

Attacks on Health Care

Since the outbreak of hostilities in Amhara in August 2023 through at least May 2024, the Ethiopian military and other security forces have carried out attacks on health care in 13 towns in northwestern Ethiopia's Amhara region. These forces have unlawfully attacked ambulances and medical transports; beat, arbitrarily arrested, and intimidated medical professionals; obstructed access to medical facilities, including by wrongfully arresting patients on mere suspicion of a Fano affiliation; endangered or disrupted the functioning of hospitals; interfered with access to humanitarian assistance; and denied the Amhara population the right to the highest obtainable standard of health.

Attacks on Ambulances and Transport

Witnesses and residents of Wegel Tena town, in South Wollo Zone, told Human Rights Watch that an airdropped munition, most likely from an Ethiopian air force drone, struck a clearly marked ambulance and killed at least four civilians and badly wounded one on the afternoon of November 30, 2023.^[69] While there were no clashes in the area or fighting nearby, doctors and residents believed that Ethiopian government forces deliberately attacked the ambulance to prevent medications from potentially treating Fano fighters who were present around the town at the time of the attack.^[70]

That afternoon, the ambulance was transporting three healthcare workers from the Delanta primary hospital in Wegel Tena back from the Ethiopian Pharmaceutical Supply Agency (EPSA) branch in Tita town near Dessie after procuring much-needed medical supplies for the hospital.^[71] Onboard was Bizuyehu, the driver; Henok, the pharmacist; and Dr. Getachew, the hospital's CEO. All sat in the front seat; medications and supplies were in the back of the vehicle.^[72] Three residents said they saw what they described as a drone flying in the area on the day of the attack.

While Delanta hospital did not receive many injury cases directly related to the fighting in the Amhara region, one medical professional said that the hospital was struggling to recover after Tigrayan forces looted medical supplies and equipment during the earlier fighting in northern Ethiopia.^[74] Since the outbreak of armed conflict in Amhara in August 2023, the hospital was managing a growing number of patients including those suffering from infectious and communicable diseases due to a cholera outbreak and trauma patients, all with limited medical supplies. "We were trying out best," said one doctor. "We were committed to treating the patients.… Our problem was the shortage of supply."^[75]

Two town residents said that Ethiopian military forces at the time controlled at least three checkpoints on the route from Tita to Wegel Tena. One health worker from Delanta hospital said that he frequently called and checked in with his colleagues as they travelled back to Wegel Tena:

My colleagues said they encountered no problems and that Ethiopian forces allowed them to pass after thorough inspection of the ambulance and of the occupants. If there had been any suspicion, they could have prevented their travel rather than bombing them.^[76]

The ambulance was hit on the outskirts of Wegel Tena town, around 4 or 5 p.m., about 1.2 kilometers from the hospital. Human Rights Watch analyzed two photographs found online, two videos sent directly by sources, and available satellite imagery to determine the exact location of the ambulance when it was attacked.

Four residents said that on the day of the attack, Fano fighters were present in parts of the town, but there was no active fighting.^[77] Human Rights Watch is not aware of any Fano fighters being near the ambulance at the time of the attack.

Several residents heard a blast but did not know what had happened or how to respond. "I heard a loud explosion," said one town resident. "We only heard it once. We were afraid that there would be a second attack, so not many people dared to go to investigate what happened right after."^[78] A doctor working in the emergency room at the hospital said they heard the explosion, saw an aircraft in the sky hovering around the hospital, and heard the distinctive buzzing sound of an unmanned vehicle overhead.^[79]

Another resident saw "the drone scanning the sky that day," and added, "the drone stayed in the sky after the attack and was getting lower and lower, so we were afraid to help people. We were afraid of another attack."

Some residents rushed to the site of the attack but were turned back by Fano fighters. One man said: "We ran in the direction where we saw smoke, but Fano coming from the western part of the city shot into the air to turn people away, saying there might be another attack if people gathered around the area."^[81]

Dr. Getachew, the CEO of Delanta hospital, was in the ambulance and managed to escape by crawling through a broken window shortly before the vehicle ignited in flames killing the other passengers, Henok and Bizuyehu, as well as two bystanders.^[82] One resident who rushed to the site of the attack and saw the ambulance engulfed in flames while the drone still flew overhead, said:

Some people started to throw water and soil, but the fire got stronger, and the medicine was bursting apart in every direction.… [I]t wasn't safe anymore. The drone was still present, and people were afraid there would be another strike.

I still remember the driver burning. His hand was outside the window.... All of us were in shock, and trying to help the best we could.^[83]

Human Rights Watch verified a 16-second video, filmed between dusk and nightfall, that showed the ambulance on fire with the roof caved in.

Tamene, a 35-year-old father of four, was one of the bystanders killed in the attack. He was building a house for his family off the asphalt road, when the munition struck the ambulance as it passed by the house. "I didn't know Tamene was a victim of all this," said one resident. "We were all in shock, trying to help as best we could. Tamene was taken to the hospital and later died.… [H]e had been injured around his neck and head."^[84]

Another resident that visited the site the following day described the horrific scene:

It was a difficult thing to witness. I saw dismembered arms. Fingers charred and clutching a melted phone.… The medicine was still burning and there was smoke and a smell."^[85]

Human Rights Watch analyzed and verified two photographs that showed a burned-out ambulance, which circulated online in the aftermath of the attack. One photograph captured the rear of the vehicle where, what looks like, small packages, consistent with medicine, spilled out of the open backdoor.

Those killed were buried the following day. A family member of one of the victims said: "When we saw him … I don't know what to tell you, maybe charcoal is the closest way to describe what was left of [him]. He was covered in a fabric … and we buried what remained."^[86]

The attack left a lingering impact on the town. Over a month after the strike, Dr. Getachew was still recovering from his injuries and the trauma of the attack and needed further specialized treatment to remove fragments from his body.^[87] His colleagues and members of the community were also affected. One doctor further conveyed the toll on the hospital in January:

Psychologically, hospital staff are disturbed and living in fear of another attack.… The drone was flying and scanning for almost two weeks after the attack. Staff were terrorized, unable to focus, and even missed work. All the medications in the ambulance burned. We had used the little budget we had left to procure the medications. We used the ambulance both for referral, emergency, and medication transport. Now we have no other vehicle … this was an unaffordable cost.

Satellite imagery dated February 5 shows that the ambulance had not been recovered or moved from the location where it was attacked.

Human Rights Watch tracked, using satellite imagery, the presence of Ethiopian armed drones across different airbases in Ethiopia.^[88] Two hours prior to the attack on November 30, three Turkish-produced Bayraktar TB2 drones and a ground control station were visible at the hangar of Harar Meda airbase in Bishoftu, Oromia. Ethiopia's drone arsenal also includes Iranian and Chinese drones. Human Rights Watch was not able to confirm if any of these drones were responsible for the attack on the ambulance.

The attack against the Delanta ambulance was not an isolated incident. Since the start of the conflict, warring parties have on several occasions compromised the ability of civilian patients to receive treatment by unlawfully seizing or firing at ambulances and transport carrying medical personnel or those wounded or sick.^[90]

A medical professional in South Achefer district, West Gojjam Zone, said that Ethiopian soldiers seized the hospital's ambulance in November 2023 after accusing medical professionals of providing treatment to Fano fighters. He said: "We can't maintain an ambulance, so people are now forced to take patients from our hospital using private vehicles."^[91] Similarly, a doctor in Debre Tabor town in South Gonder Zone said that women in labor resorted to giving birth at home due to the unavailability of the hospital's ambulance which, according to him, was "instead serving the military and local authorities."^[92]

Another professional working in a hospital in North Gonder Zone said that Fano forces seized ambulances from two different health institutions in the town, hindering the ability of wounded patients in the town to receive timely and critical care. He said:

Patients were critically injured after Fano fighters tried to take over the town. Three kids arrived at our hospital with blast wounds and needed referrals to Fellege Hiwot hospital in Bahir Dar. We couldn't send them using our ambulance since it had already been confiscated by Fano. The family members of one injured child carried him using a makeshift bed to a nearby town, hoping to catch a motorbike from there to Bahir Dar. He died en route. He was maybe 6 or 7 years old.^[93]

Threats and Assaults against Healthcare Workers

Health institutions should be left out of the 'blame game' in the war. Our profession is to give service impartially to whomever needs medical attention. Our only concern is to keep people alive. The pressure on medical professionals should be stopped - they should let us do our work.

- Dr. Getahun, North Gojjam Zone, November 2023

Ethiopian security forces have threatened and beaten medical professionals and staff, accusing them of treating or providing care to perceived Fano fighters in several towns across the region.^[94]

In Awi Zone in September 2023, government soldiers threatened a 32-year-old hospital administrator at gunpoint after he refused a demand to turn over medications to the Ethiopian military.^[95] He said:

The [soldiers] forced my colleague to show them where I lived, and they came to my house in four patrols.... I wasn't at home, so the soldiers called me [on the phone] again.... They told me to wait at the security gate of the hospital. I went, thinking I had no options. Once I got there, they were very angry.

One accused me of being Fano.... I told them I give medicine based on prescriptions and need and that I am a public servant protecting the government storage. The soldier replied, "There is no government now." He ordered me to kneel, slapped me and urged the other soldiers to kill me, to shoot me. My colleagues started crying, begging them not to do anything. At one point he stopped.... I was traumatized, imagine being threatened at gunpoint with no crime.^[96]

In mid-January, a few days after Ethiopian Orthodox Christmas, government forces comprised of military personnel, anti-riot police, and local militias accused medical workers at a health center near the regional capital, Bahir Dar, of providing treatment to wounded Fano fighters.

"They were around 60 security forces," said Mulualem, a medical professional at the center. "When they came, they asked whether we treated injured people. I answered and said of course, this is a clinic, we give treatment to whomever needs it."^[97] Mulualem said the soldiers demanded to see the records of patients, specifically those treated at the center on January 3, a day in which there was reportedly heavy fighting. When doctors refused, the soldiers searched for patient files themselves. "They started insulting us, saying how dare we treat Fano using government money," said Mulualem. Ethiopian soldiers then detained him and took him to a nearby town. He said:

They took my phone and searched for it but couldn't find anything. The colonel [interrogating me] called me a "Fano doctor." I told him I was just doing my job, that I'm just a doctor. He started asking why I was giving treatment to the Fano. He said [the Fano] are not humans … they are monsters. He blamed us doctors for making their lives more difficult. He told me the [Fano] fight them and get injured and then doctors give them treatment and heal them, allowing [the Fano] to fight the military again. He told me: "You are going against your country."

Mulualem said that they then handed him over to a lieutenant for further questioning:

He asked me the same questions as the colonel. He started calling out a list of names, including patients we treated at our hospital on the date of the [January 3] battle. He demanded to know where they were hiding.... But I had nothing to share.... He started getting angry while smoking his cigarette and said I would pay the price.^[98]

After four days, the soldiers released him.

Asfaw, a doctor working in a West Gojjam Zone hospital, said that government soldiers beat the hospital's medical director after he returned from Bahir Dar with critical medications and other supplies in early January 2024. Asfaw recounted what his injured colleague told him when he was receiving care at the hospital:

He was at the entrance of [the town] and was searchedby defense forces. They accused him of bringing the items for Fano and beat him so badly he lost consciousness.… We were worried he had internal bleeding, so we referred him to a hospital in Bahir Dar for treatment…. He was discharged after a few days and is back in town now, but it's been more than a week and he still hasn't returned to work.^[99]

Asfaw said that soldiers regularly humiliated or threatened staff at the hospital. He said that following heavy clashes in the town in August 2023, soldiers entered the hospital, claimed it served as a "Fano hospital," and shot at the generator, leaving the hospital to function without electricity for days due to electricity cuts in the area. Soldiers came into the hospital again in September and threatened staff. Asfaw continued:

They took staff to a road that was blocked by rocks and forced them to remove the rocks. Staff members have also been slapped. When the military brings injured soldiers, they threaten staff by saying "Take care of him - if he dies it's on you."^[100]

Health workers said that the hostility of government forces was affecting their ability to do their work.^[101] "We can't serve people in our profession, we are questioned for doing our work," said a health professional at a government health center.^[102] A doctor at a Bahir Dar hospital treating wounded government militias said:

We have a blood shortage, so there was a delay in getting the [militia members] cared for. But they think it's because we don't want to treat them. They even wanted to hurt us. It's challenging for us to treat them let alone be around them.^[103]

A 35-year-old doctor in North Gojjam Zone said that the security forces' repeated harassment forced healthcare workers to simply stay home if heavy fighting took place in or around the town, as that was when reprisals against health workers were more likely. He said that, "Physicians don't feel comfortable in our profession … so when fighting breaks out, some people prefer to be home."^[104] In October the hospital suspended its services all together, hindering the ability of patients in the area to receive care. The doctor added: "[The fighting] started inside the city so we decided to close the hospital and go home ... We are the only hospital in the city."

Threatening phone calls drove one medical professional into hiding. He said:

I received a threatening phone call saying that I had a relationship with Fano, that I was helping, giving medical treatment to Fano. I'm a doctor, I don't know who is coming to the hospital, I just give medical assistance to whoever comes. But I felt fearful so after this I fled.^[105]

The doctor eventually left the Amhara region altogether. "They were threatening me. They started to threaten my family. When it escalated to this level, I had to leave."^[106]

Ill-treatment and Attacks on Wounded and Sick

More than 100 soldiers came to the hospital and started searching everyone there: everything, every room. The staff are already frustrated. Because we are accused of treating the Fano every time. When they come, we can't say anything, because we don't want to risk anything. We have no guarantees.

- Dr. Girma, Durbete, December 2023

Ethiopian security forces have interfered with medical treatment and threatened and obstructed access to health care during the conflict in the Amhara region by repeatedly entering and searching hospitals in a disruptive and abusive manner. They have sought out wounded men, taking bullet or shrapnel wounds as evidence of participation in fighting or affiliation with Fano, particularly in the aftermath of heavy fighting.^[107]

Under international humanitarian law, military forces may temporarily enter medical facilities for legitimate purposes, such as searching for, detaining or questioning alleged security threats or enemy fighters. However, such actions should not disrupt the normal running of medical facilities, and armed personnel may not interfere or deny medical treatment.^[108]

A doctor working at a hospital in North Gonder Zone said that in November 2023, a wounded fighter was brought to the facility when government forces, who were already using the hospital unlawfully as a military base, stopped doctors from providing treatment and summarily executed the fighter. "He was injured in the leg…. [T]he [soldiers] took him to the back and shot him. The military [later] buried his body in the back of the compound."^[109]

In a similar incident in Bahir Dar, Amnesty International verified the execution of a 20-year-old man by a government soldier in October 2023, while the young man was receiving treatment at a health center in the city's Seba Tamit neighborhood.^[110]

Eight health workers across six towns in the Amhara region explained how government forces, including members of the Ethiopian military, Amhara police and militia, often raided hospitals after battles in search of wounded individuals and arrested those, including civilians, seeking treatment on suspicion they were wounded fighters.^[111]

In mid-January, a medical professional working in a hospital in West Gojjam Zone said they saw Amhara anti-riot police forces and local militia enter the facility and remove a patient who was shot outside of his hair salon. The medical professional said:

He was leaving work when he was shot. Soldiers brought him to our hospital. He was bleeding. Staff began cleaning his wound and putting an IV drip when the government forces came and accused him of being Fano. They began arguing with the doctors who explained that the patient was losing blood and needed treatment. But the forces refused. They removed the IV drip and took him.^[112]

In late September 2023, government forces regained control of Gonder, the second-largest town in the Amhara region, following renewed clashes there.^[113] Two doctors on call said that 20 to 30 soldiers entered the University of Gonder Teaching and Referral hospital in search for what the doctors believed were wounded fighters. ^[114] One doctor said: "The [soldiers] came into the hospital and … went as far as the operating room. They started looking for patients, bleeding or injured, and started taking them. These weren't Fano fighters, they were civilians injured by stray bullets during the clashes."^[115]

Government forces ended up taking five injured patients, all men.^[116]

"They didn't communicate with us much, but I heard someone instructing them on their radio that 'if anyone resists, deal with them,'" explained one doctor."[E]veryone was scared, no one tried to argue with them, but as a medical professional witnessing this, you feel very sad."^[117]

The doctors said that security forces returned all but one injured man to the hospital the following day.^[118]

International humanitarian law prohibits warring parties from making distinctions on care based on considerations other than medical need and from punishing medical professionals for engaging in care consistent with medical ethics.^[119] A doctor in a South Gonder Zone hospital said that in some cases, government forces gave priority to their own wounded over the needs of other patients:

They [soldiers] brought a local militia member shot by Fano and ordered us to take a patient out of the operating room. The patient we were treating was bleeding and needed care first. But they didn't care. We asked them to pay for the services they needed, but they refused…. [T]hey don't care for the community.^[120]

Healthcare workers and doctors expressed frustration with the government's interference with medical care and their inability to provide care for those who required it.^[121] A doctor in a South Gonder Zone hospital said that a teacher from a rural area was receiving treatment when local police, against medical advice, arrested him on suspicion of being a Fano fighter.^[122] He said:

The teacher was injured by Fano forces and was referred to our hospital because there were blood shortages in his area. The police were informed and [the teacher] was taken to the police station. He needed a blood transfusion, but was without any care, nurses, saline, or antibiotic for 48 hours…. As a professional I want to treat any patient that can access the hospital.^[123]

Similarly, a doctor at a Bahir Dar hospital said that government militias regularly raided the hospital:

This is very dangerous…. They [the militias] don't respect the neutrality of the hospital. It's challenging for us to give support to those wounded. Whenever someone is injured, they suspect they are Fano ... they'll go as far as the operating room…. They don't want them to get treated, they want them to be taken out of the hospital and imprisoned.^[124]

A doctor in a South Gonder Zone hospital said government forces have suspected patients suffering injuries unrelated to the fighting. He said: "They consider any orthopedic patients as injured due to the war, as if they are members of Fano." He recalled government forces arresting a young male patient with an abscess wound in November 2023. "They took him to the police station and sent his family to our hospital to confirm," he said. "We had to write them a letter, describing the medical condition. They still had to come to the hospital to check [his diagnosis] for themselves."^[125]

Endangering and Interfering with Hospitals

Throughout the conflict in Amhara, Ethiopian government forces have deployed near hospitals and other health centers, placing medical facilities, health workers and patients at grave risk. At times they have occupied the hospitals, making them subject to attack as valid military targets.^[126]

Under international humanitarian law, parties to the conflict are obligated-to the extent possible -to avoid placing military targets such as troops or weapons within or near densely populated areas.^[127]

In mid-October 2023, Ethiopian defense forces and Fano fighters clashed outside Tibebe Ghion Comprehensive Specialized hospital in the Amhara regional capital, Bahir Dar, affecting the movement of patients and hospital staff. A witness said the fighting was a few meters from the hospital's main gate. He continued:

Some Ethiopian defense force members then entered the hospital and positioned themselves on the terrace of the hospital…. The fighting was for a brief period, but we were affected by this. Government forces took bystanders hiding from the fighting in the hospital compound. Transport and ambulance services, movement was suspended, and government forces repeatedly intruded into the hospital for a week.

In August 2023, artillery shells hit Debre Tabor hospital in South Gonder Zone, wounding civilians in the area after fighting broke out between government forces and Fano fighters.^[129] One doctor working that day described government forces firing from one side of the hospital building and the damage and toll of the fighting in the town on the hospital:

We were stuck for around 56 hours in the building. We couldn't move at all…. A screening machine given to us by an international NGO [nongovernmental organization] and worth around 3 million Ethiopian Birr (US$53,000) was damaged. The glass and doors of the maternity and pediatric ward were damaged…. A staff member's husband died when he was struck by a bullet in the hospital compound … a security guard was also injured.^[130]

Another doctor at the same hospital said admitted patients left the hospital altogether because of the fighting, leading to further casualties: "We learned that a patient suffering from cardiac conditions and one with diabetes left the hospital, died at home … another patient that left the hospital, was lying dead on the road, maybe 100 meters away from the hospital. He had previously been on oxygen."^[131] He added that while the physical damage wasn't extensive, "as it is still a hospital, it should be kept safe."

In late October 2023, intermittent fighting between government forces and Fano fighters also caused temporary disruptions to medical services at a hospital in North Gojjam Zone. "We had six or eight patients in the hospital, but when fighting started in the city, all the people were forced to go home," explained one 35-year-old doctor.^[132] "A lot of people were scared; most patients didn't come. The ones that were coming into hospital couldn't get treatment, because physicians were not in the hospital."

Obstructing and Hindering Access to Medical Treatment

The people need medical care, but the roads are blocked, they can't find medical transport … so they're staying at home.

-Dr. Mulugeta, Debre Tabor hospital January 2024

The conflict in the Amhara region has severely hindered the population's ability to access essential and timely health services and treatment. Frequent roadblocks and the presence and operations of military forces in the region have significantly hindered access to medical care.

A doctor at a hospital in North Gojjam Zone said that on one occasion, 40 to 50 government soldiers deployed around the building, preventing entry, including for doctors and patients:

They surrounded the hospital and blocked the gates…. I was out for lunch [with colleagues] and when we came back … we were scared to go inside. We called colleagues inside and heard soldiers were forcing staff to go through admission cards and that if they gave treatment to Fano it would be on them.^[134]

A nurse at the same hospital described the impact of the military presence at the hospital on patients:

Of course, patients are intimidated when they see soldiers in hospital. If they come, they would wait outside. If patients are in a line waiting for service or treatment, and the military comes, the patients will give them priority. They are just afraid of them.^[135]

Similarly, after heavy fighting took place in a town in South Achefer, soldiers surrounded the hospital, preventing access to medical treatment. A doctor working in the hospital said:

The military came straight to the hospital and started guarding around the hospital. Whether it was civilians, or Fano fighters, whoever needed help, couldn't come. We are here to serve everyone, but because the military is in the cities and hospitals, people are afraid to go get treatment. Even those with minor or major injuries are not coming. People we could have saved are dying in their homes.^[136]

In Dembecha, West Gojjam Zone, a healthcare worker told a journalist that federal forces camped out in the town's hospital "for days," making it difficult to provide health services.^[137] A doctor in North Gonder Zone similarly told Human Rights Watch that in late November 2023, Ethiopian armed forces resumed control of a town and occupied the hospital. "They brought Kalashnikovs [assault rifles] and snipers and entered the hospital," he said, which left both doctors and residents fearful." He added:

Even if the hospital is still technically serving its routine function, it is serving as a shelter for them…. The [soldiers] don't mention how long they will stay…. They are using the hospital resources for themselves.^[138]

Birte said that military forces shot her 16-year-old brother in Sanja town, North Gonder Zone in early August 2023, but he struggled to get care due to movement restrictions imposed by government soldiers. She said:

My brother was sleeping when he was shot and couldn't go to the hospital because no one was moving or allowed to leave their homes. It was after only three days that he went to the hospital in Sanja. But they couldn't treat him there. They wrote him a referral, but even then, he had to wait until the roads were open.^[139]

A doctor in North Gonder Zone described treating a patient who suffered complications after being shot by Ethiopian soldiers due to delays in seeking treatment: "The patient, a farmer, fractured a bone in his thigh when he was shot. While he survived, his wound is infected since it took him one week to get to the hospital. He lives 70 kilometers away, and transportation is difficult because of roadblocks."^[140]

Several doctors said that pregnant women were unable to receive adequate and timely care and were at risk of experiencing pregnancy and birth-related complications due to roadblocks, movement restrictions, and the unavailability of ambulances or transport.^[141] Sisay, said his sister, who lived in a village in South Gonder Zone, experienced complications during labor, but couldn't get referred to emergency obstetric care. He explained:

My sister was in labor, but she was losing a lot of blood. Family members took her to a health center in the village, but she needed to be referred to a hospital in a nearby town. It was already nighttime, and she couldn't get an ambulance because of the curfew. People that would help in transporting her couldn't, because they were afraid the soldiers would arrest them. We had to wait until the next day, to take her to the town's hospital using a donkey cart. We are lucky she and the baby survived.^[142]

During armed conflicts, maternal deaths often occur during delivery or in the immediate post-partum period due to lack of availability of quality reproductive and maternal care, including, emergency obstetric services, and pre- and post-natal care.

A doctor at a Bahir Dar hospital lamented how the frequent roadblocks, whether controlled by Fano fighters or government forces, sometimes compelled, even those in need of urgent care, to stay at home. He said:

So many patients are not arriving at the hospital in time…. They don't even try to move on foot, because it's not safe…. By the time patients come, cases may get more complicated…. A patient with appendicitis came days after it spread to the abdomen, so instead of getting discharged in a day, they have to get an operation and stay weeks [or longer].^[144]

A doctor at a rural health center said that patients refused necessary referrals to hospitals in larger towns due to rumors that government forces were arresting patients there. He said: "We don't have the required tools…. We can't do referrals…. [The patients] are scared to go to the other hospitals…. They tell us, just do what you can."^[145]

Several doctors and healthcare workers said that in addition to the roadblocks, the seizure and attacks on ambulances by warring parties further prevented the ability of doctors to receive patients and for civilians to obtain care.^[146] One doctor in West Gojjam Zone said that the hospital's ambulance was essentially "non-operational". He said:

The numbers of patients have decreased because people are afraid of being accused as Fano. The ambulance drivers are not willing to fetch patients, they fear that the Ethiopian military may stop them an accuse them of transporting Fano. They worry if the Fano stops them, they will get accused of transporting the military.

Another doctor in South Achefer said that patients were out of reach as a result:

[One area] is under the control of the military, but the south and north are under Fano. What this has brought is that we can't refer patients to other hospitals from these areas because it's not safe. The ambulances get attacked, drivers and staff get attacked, so no one wants to go to these areas anymore.^[147]

Access to Humanitarian Assistance

So many people are dying. With the number of people we have to give attention to, hospitals are running out of things. It is not fair to punish the people medically. The government needs to see that the conflict is not related to medical care. Professionally we have a responsibility to give treatment to whoever needs help. The hospital needs to function, but with the medications running out, I don't know how we will help our people…. The humanitarian situation of the hospital needs to be separated from war.

- Dr. Solomon, West Gojjam November 2023

The conflict in Amhara is exacerbating an already dire humanitarian crisis in the region.^[148] The UN identified 66,153 people displaced in 88 sites between August and September 2023, primarily due to ongoing fighting in the region. The estimated number of people requiring food assistance in 2024, according to the government's own assessments, particularly in drought-affected areas, is over three million people. ^[149] Further compounding needs is the outbreak of communicable diseases, with the Amhara Public Health Institute recording 328,279 malaria cases between July and October 2023, and first reporting a cholera outbreak in July 2023.^[150]

Despite the growing scale of needs in the region, humanitarian access remains a challenge for aid agencies.^[151] "We aren't facing the kind of obstruction we saw in Tigray," said one aid worker, who added that the volatile security situation made it difficult to access the region and provide aid. The aid worker said:

Control of areas are frequently changing hands. There are no security guarantees…. Partners may not have the right contact with armed groups, and we need a letter from the command post to move. You have to inform so many authorities, this is a barrier. And depending on whom you are, you may not get a letter … and if you don't distribute in Fano held areas, you are accused of supporting the defense forces.^[152]

Another aid worker added: "There was a time you could go from Gonder city to Bahir Dar city by land, but then all of a sudden it is not safe, and you have to travel by plane … It changes constantly, [the armed actor] in control ... and every time there is a change, the levels of permission change. There is no consistency."

The UN reported that in the Amhara region they faced the highest number of obstacles to their access in 2023, with insecurity continuing in 2024.^[154] The UN Logistics Cluster, responsible for coordinating aid delivery and distribution in Ethiopia, reported "756 security incidents in the Amhara region between March and April 2024, including 14 restrictions of movement, 19 incidents of violence against humanitarian personnel, and 697 active hostilities."

Nine aid workers were killed in Amhara since fighting started in 2023, while at least four aid workers have been killed since January 2024. In the most recent incident, on May 24, unidentified gunmen fired at Medical Teams International convoy as it was travelling in Amhara killing one staff member and injuring others. Frequent road closures, the looting of humanitarian supplies, and seizure by gunmen of vehicles transporting supplies has further constrained the populations access to basic necessities.^[157]

An aid worker said in February that, "The only way to reach the Amhara region now is by air because it is unsafe to travel by road."^[158] Even then, aid travel is limited due to prohibitive costs charged by Ethiopian Airlines, a government-owned airline, and the increased costs associated with distributing supplies from major towns to regions.^[159] The aid worker added:

These are small planes and can only take one metric ton of supply per flight…. The Ministry of Health, a government agency, is unable to afford to send supplies by air! Even when we transport to Amhara … we need to deliver supplies from Bahir Dar, Gonder, Kombolcha, to health facilities. We need to rent trucks, hire drivers to access these areas, this is expensive, and we need the funding to back that up.^[160]

Another aid worker said: "We can deliver supplies to main cities, but someone still needs to pick them up. It is the hospital [workers] that are putting themselves at risk … and we pay them just some per diem."^[161]

A doctor in Awi Zone confirmed that even with aid that enters the region, the risk of and costs of retrieving desperately needed supplies are borne by his hospital and his staff.
He said:

There was a time when the Ministry of Health gave us gloves, ringer lactate, surgical gauze, and first aid equipment, but even that wasn't enough…. They don't want to come here, because a road open in the morning could be closed by the afternoon. They don't want to take the risk, so we have to go get it from Bahir Dar.^[162]

Shortages of Vital Healthcare Supplies

Doctors in the region also consistently told Human Rights Watch that the conflict in Amhara has disrupted vital medical supplies, impairing the ability of hospitals to remain functional.

Warring parties' actions have obstructed civilian access to functioning health care and undermined the availability, accessibility and acceptability of good quality health facilities, goods and services, especially for groups rendered vulnerable by the conflict. In September, the International Committee of the Red Cross (ICRC), in a statement on Ethiopia, said that "hospitals are struggling to care for the wounded and critically ill in areas where the security situation is particularly unstable."^[164]

A UN situation update in December 2023 reported the limited capacity of health institutions in the Amhara region, particularly in the Gojjam Zones, to provide basic health services, due to the reported damage of health facilities, and the lack of essential drugs, testing, and treatment kits.^[165] In February 2024, ICRC found that before receiving ICRC support, the Woybegin Health Center in West Gojjam Zone lacked adequate medical supplies and equipment such as antibiotics, and was forced to purchase surgical gloves and other supplies from private clinics. The report added that at Debre Markos Comprehensive Referral Hospital, in East Gojjam Zone, patients incurred additional out-of-pocket costs by having to purchase gloves and medical supplies from private pharmacies in order to receive care.

"Health facilities are empty," said one aid worker in February 2024. "They don't have drugs. We already have a humanitarian crisis on our hands. And it will only get worse."^[167]

In the past, shortages in drugs and medical equipment were resupplied by Ethiopia's Pharmaceutical Supply Service (EPSA), a government agency that imports and procures drugs from international agencies, local manufacturers, and importers.^[168] The agency is also primarily responsible for distributing medicines to government health facilities. "The challenge is that the EPSA branch here is telling us they don't have medicines to give us, and Amhara regional Zonal authorities [administrative authorities in the region] are saying they have no budget to procure medicines," said Addisu, a civil servant who works in the health sector in the region.^[169]

Worsening economic conditions in the country, including a foreign currency shortage and rising inflation exacerbated by conflict and global supply chain disruptions, had already increased the costs for EPSA to procure drugs for Ethiopia's health system in early 2021, which is heavily reliant on the import of pharmaceutical products.^[170] The destruction of the Addis Pharmaceutical Factory in Adigrat during the two-year armed conflict in Tigray, one of the largest local manufacturers in the country, also contributed to the shortfall.^[171] Officials at EPSA told local journalists in November 2023 that they have been unable to deliver medicines in Amhara due to fighting that blocked road transport.

Doctors in the region have struggled to provide adequate care amid the shortages of medical supplies and equipment. A doctor in a Gonder city hospital explained how in August 2023 he had to perform emergency procedures while running out of oxygen, water, and electricity: "One patient died while on a ventilator for support. The oxygen plant is 70 kilometers away, in Bahir Dar, but the roads need to open for safe transport."^[173] Shortages continued to exist months after. He said in early December:

We had to do caesarean for a pregnant woman. To your surprise, her abdomen, should have been washed … it should have been with alcohol, but we had to just wash with water…. No one will give you the right reason, some will say this is because of the lack of budget. Another person will say insecurity, someone else will say because of bureaucratic reasons … but supplies are limited.^[174]

Shortages of oxygen, electricity, and fuel have prevented health workers in other hospitals in the region from treating the wounded or providing other essential services to patients. "Patients that need a blood transfusion will sometimes stay two or three weeks in the hospital until they can get blood. They think it is because health professionals are unwilling to treat them, but it is because we have blood shortages," said a medical professional in a Bahir Dar hospital. "We're struggling to give care to patients that need surgery."^[175]

Three doctors interviewed said that hospitals were also running low on fuel, needed to support ambulance services as well as the operation of generators, due to frequent power interruptions in the area.^[176] In November 2023, Solomon, a medical professional in a West Gojjam Zone hospital, described some of the challenges he faced:

We have shortages of oxygen and medication, and since there is no power, we are struggling. The blood bank has stopped collecting blood. We have to conduct cesareans. Yesterday, we had to tell the expectant mother's family to come with 20 liters or any amount of fuel they can bring so we can operate on them using the generator.^[177]

The lack of critical supplies forced hospitals in South Achefer district, in West Gojjam Zone, to support one another for some time, said a doctor in November 2023. "In the past three or four months, whenever we had shortages of supplies, we used to borrow from each other, but we can no longer do that." Shortages were so severe; he feared the hospital would have to be forced to shut down. He added, "We are fighting to keep our lab and operating rooms open, but the equipment and drugs we have are depleted…. We can't even buy bleach to clean floors…. We are really struggling.^[178]

Tsegaye, a medical professional working in North Gojjam, described his hospital as being in a "paralyzed state" due to shortages. "We don't have things to save people. We've run out of medications for patients. This was a hospital that served three weredas [administrative districts] …. The only reason the hospital is open is to give care to older patients and women who need to give birth."^[179]

Several doctors said that government hospitals simply lacked a budget to pay for medications to restock supplies.^[180] In Ethiopia, the government, bilateral and multilateral donors, and out-of-pocket expenditures fund the healthcare sector, while regional governments, such as in Amhara region, would draw their own budget based on grants from the federal government, which they can subsequently allocate per sector, including for health.^[181]

According to 2021 figures, based on a World Health Organization (WHO) database, the Ethiopian government spent the equivalent of 0.98 percent of its gross domestic product (GDP) on health care or around 7 percent of its national budget. This level of public healthcare spending is far below international benchmarks, including from the World Health Organization, which are associated with improved healthcare access and outcomes, such as spending the equivalent of at least 5 percent of GDP or 15 percent of the national budget on health care.

This lack of public support worsens inequalities of health access and outcomes by placing the burden of financing health care on individuals and households, who collectively paid more out-of-pocket on health care than their government spent on it in 2021. It also falls short of specific commitments that the government of Ethiopia made in 2001 alongside other African Union states to allocate at least 15 percent of their national budgets to improve health care. However, according to these data published by the WHO, 20 years after making this public commitment, Ethiopia's national budget allocated less than half of that. While a 2022 UNICEF report cited different figures than those published by the WHO, which were based on data from the Ministry of Finance, it still found that the government's spending on health care was below its commitments to allocate 15 percent of its national budget.

Several medical professionals attributed the lack of support to public hospitals to the collapse of administrative structures in the Amhara region.^[185] While the government acknowledged that armed groups took over towns, including government institutions in some towns in Amhara, and also targeted government officials, the region is also under a militarized command post to implement the state of emergency. The command post system not only restricts rights, such as movement and expression, but centralizes military, law enforcement, and civilian authority under one security structure.^[186] The state of emergency in place in Amhara since August 2023 suspended the civilian authority that would normally manage and assess the provision of social services, including management of the health and education sector.^[187]

A doctor at a government hospital in South Gonder Zone described the impact of the command post system on the health sector: "We can't get the money…. It is managed now by a command post. There is no specific budget for the health system." ^[188] Another medical professional in West Gojjam Zone said:

The bodies responsible for different parts of the system are no longer in place. That complicates the transactions within the working environment. In addition to that, there is also a budget deficit. When they give us the budget, it is not enough. With the high inflation happening [in the country] we can barely stock what we have.^[189]

One medical professional, working in a hospital that served a catchment population of around five million, explained that the hospital was no longer reimbursed for the services they provided to patients on a community-based health insurance plan. He said: "Some of the agencies are not functioning … because the offices are closed. Other agencies' offices say they can't collect the money to pay us…. Our operating budget is less than in previous years…. Getting any additional budget is a challenge, in the past we would request it from the Ministry of Finance, but they're not able to provide it."

Shiferaw, a doctor in Awi Zone expressed his concerns that the facility might be forced to shut down:

We are having problems with doing day-to-day activities. The budget hasn't been released. The [administrative] structure is no longer in place. Almost all our patients used national medical insurance, which is no longer reimbursed to us. We don't have the budget to buy fuel or any medications. We are working now until we run out of whatever we have in our hands.^[191]

With the lack of availability of medications in hospitals, and budgets increasingly unavailable, patients on community-based health programs-which enables access to health care for millions of households in the country-may no longer be able to obtain medications or care for free at government hospitals as they once used to.^[192]

Blen, who was raped by multiple perpetrators in front of her children in West Gojjam Zone, told Human Rights Watch that she needed post-rape treatment but could n0t afford the care:

I have so much pain. I feel it almost daily, but when I've gone to the clinic, they can't help me. For the health checkup, we used to use the government medical insurance, but now that has run out. You can only get service if you pay. I can't afford to go to the clinic anymore since I can't work.^[193]

Biniyam, a day laborer in Dembecha town, West Gojjam Zone, believed the government hospital in the town was "just open as a formality." "People can't get medication from there," he said. "They don't have anything. So, people are forced to buy from private pharmacies…. Even that is becoming a challenge. Most people used to use government insurance, but it is of no use because they can't find anything there."

Patients on government insurance, which covers most outpatient and inpatient services at government health centers, are instead instructed to purchase prescriptions at private pharmacies, where the costs alone are prohibitive for many. Haile, a diabetic patient on government insurance in a West Gojjam town said:

The hospital is technically open. Doctors are there, but you won't find any supplies…. With the government insurance, we paid 500 Ethiopian Birr [US$8.81] a year, and the medications were free at government institutions. But since you can't find the drugs you need; you have to go to the private pharmacy…. The last time insulin cost me 170 Ethiopian Birr [$3.00], but there is an increase in price, it can cost 350 Ethiopian Birr [$6.17] .... A lot of people are facing problems.^[195]

Recommendations

To all parties to the conflict

• Abide by international humanitarian law. Issue clear public orders to all forces to end attacks on and ensure the protection of medical facilities, healthcare workers, patients, and ambulances.
• Investigate and appropriately hold accountable those responsible for serious abuses, including as a matter of command responsibility.
• Ensure civilians in Amhara are not denied access to goods and services essential for their rights, such as food and medicine, and take all feasible steps to facilitate the safe passage of civilians seeking to leave areas under a warring party's control.
• Ensure that any restrictions on movement for people in conflict areas are legitimate, essential and time-bound, and provide exceptions for access to health facilities, goods, and services that can be exercised with minimal delays.
• Facilitate safe, sustained, and unhindered access by humanitarian organizations to all populations in need, including medical supplies, and ensure all humanitarian staff, facilities, and supplies are protected from attack.

To the Ethiopian Federal Government

• Immediately cease all actions in violation of international humanitarian law, including:
  • Attacks, harassment, intimidation, and detention of medical staff in the Amhara region.
  • Directing attacks on health facilities and transport.
  • Interfering with medical treatment or care of wounded and injured persons, including the detention and transfer of patients against medical advice or the patient's wishes.
  • Deploying forces in a manner that obstructs access to health care, particularly as a punitive measure.
• Release all medical staff and patients who have been detained without charge. Allow those charged to have access to lawyers and family members and present them promptly to an independent judicial authority for an impartial ruling on their detention.
• Ensure that all detained individuals have access to appropriate medical care (including specialized medical treatment, where necessary), and ensure the physical safety and security of these detainees.
• Ensure the protection of medical facilities from attack, by removing all armed, non-hospital security force personnel from hospital facilities and other health centers.
• Ensure that all medical records are returned to hospitals and health facilities and carry out an investigation to determine responsibility for any tampering with medical records.
• Restore mobile internet and telecommunication services to the Amhara region.
• Strengthen the legal framework to protect health staff, including by passing specific legislation that protects healthcare workers and medical professionals and attacks on healthcare facilities.
• Take immediate steps in accordance with UN General Assembly Resolution 69/132 on global health and foreign policy to ensure that all health workers in Ethiopia are protected from violence, including by enacting all necessary measures to:
  • Respect the integrity of medical and health personnel in carrying out their duties in line with their respective professional codes of ethics and scope of practice;
  • Respect the provisions of international humanitarian law and international human rights law, including the right to the highest attainable standard of health, in protecting health workers from obstruction, threats, and physical attack;
  • Promote equal access to health services;
  • Enhance and promote the safety and protection of health workers, including the collection of data on attacks on obstruction, threats and physical attacks on health workers.
• Set a goal to spend through domestically generated public funds, the equivalent of at least 5 percent of GDP or 15 percent of general government expenditures on health care, or an amount that otherwise ensures the dedication of the maximum available resources for the realization of all rights, including the right to health.

To the Ethiopian Ministry to Health

• Take all necessary steps to end the healthcare crisis in the Amhara region, including through allocating resources to ensure that public healthcare facilities in the region and in other conflict-affected areas have adequate staff, equipment, and supplies to ensure the highest possible quality of care.
• Ensure that healthcare services are available for all populations, including in areas outside of Ethiopian government control.
• Ensure adequate and standardized monitoring and reporting of attacks on health care to strengthen accountability efforts. Ensure that regional authorities and institutions are reporting any incidents to the World Health Organization Surveillance System for Attacks on Healthcare (SSA).
• Enact all necessary policies to ensure that Ethiopia's healthcare system is aligned with its obligations under the African Charter on Human and Peoples' Rights, particularly as interpreted by the African Commission on Human and Peoples' Rights in its 2021 General Comment No. 7, including by:
  • Imposing public service obligations on all healthcare service providers to ensure that healthcare services are, at a minimum, (i) available to all individuals on an equal basis and without discrimination, (ii) accessible, even in times of emergency; (iii) acceptable to the users; (iv) of the highest attainable quality; (v) effectively regulated; and (vi) subject to democratic public accountability.
  • Publicly demonstrating that any and all policies that negatively and deliberately impact the realization of the right to health (i) are temporary, (ii) pursue a legitimate aim, (iii) are necessary, (iv) are proportionate, (v) are nondiscriminatory, (vi) involve the full and effective participation of affected groups, and (vii) protect the core content of economic, social and cultural rights at all times.

To Ethiopia's Donors and International Partners, including the United States, the European Union Commission and European Union Member States (Denmark, France, Germany, Ireland, Italy, the Netherlands, and Sweden), the United Kingdom, Canada, South Korea, and Japan

• Call on parties to the conflict to uphold their obligations under international humanitarian law, including ensuring the protection of civilians and stopping attacks on healthcare in the Amhara region.

• Publicly condemn harassment and attacks against healthcare in the Amhara region and other conflict-affected areas.

• Press warring parties to remove all restrictions that impede communities' access to health care and humanitarian aid and enhance the protection of and access to health care in situations of armed conflict as set out in the UN secretary-general's recommendations to the Security Council in 2016 and UN Security Council resolution 2286 on attacks against healthcare facilities in conflict.

• Increase support to independent nongovernmental organizations providing healthcare services in the region.

• Obtain and enforce commitments from Ethiopian authorities to stop attacks on health care, cease interference with medical treatments and protect medical facilities from attacks in any financing agreement in support of health services.

• Include in all agreements with the Ethiopian government provisions for independent human rights monitoring of all programs receiving support from donors.

• Donor governments should work with the UN and nongovernmental organizations to review and strengthen monitoring of, and reporting on, attacks on health care, including ensuring disaggregation of data by type and impact of attack.

• Call for accountability for abuses and seek, greater attention from multilateral forums on the human rights situation in Ethiopia..

To the African Union

• Call on parties to the conflict to uphold their obligations under international humanitarian law, including ensuring the protection of civilians and stopping attacks on health care in the Amhara region.
• Consider suspending new deployments of Ethiopian military forces into AU peace support operations pending an independent assessment of their participation in abuses and compliance and commitment to international law.
• The African Union Commission should implement its commitments as outlined in the 2021 communiqué on the protection of medical facilities and personnel in armed conflict and consider what steps the Ethiopian government has taken in line with the communiqué to prevent acts of violence, attacks and threats against medical facilities and personnel.
• Continue to monitor, through the Continental Early Warning System, protection of civilians considerations in the Amhara region.

To International Financial Institutions

• Monitor delivery and implementation of programs aimed to improve access to goods and services essential for rights, such as health care and food, particularly in conflict-affected areas to prevent inequitable and discriminatory distribution of services.
• Ensure that third-party implementers of funded projects regularly and transparently report on obstacles facing full implementation of desired programming, including lack of permission to access specific areas; diversion of aid; lack of funding; and unavailability of local partners that meet standards of humanitarian work.
• Where budget support is provided, monitor government expenditure on health and other critical social services such as education and social protection, to ensure it meets, at a minimum, international benchmarks as a percentage of GDP and national budgets.

To the United Nations High Commissioner for Human Rights

• Continue to report on the human rights abuses in the Amhara region and provide a regular, six-month update to the HRC about human rights in the region.
• Continue monitoring and documentation of human rights abuses across Ethiopia, and report regularly on the findings.

To the United Nations Special Procedures

• The UN special rapporteur on the right to health should send a request to the Ethiopian government to visit and assess the human rights situation in Ethiopia.
• UN special procedures mandate holders should also collect information on all health facility attacks in Ethiopia, press the government to fully investigate them, and recommend avenues for accountability.

To African Commission on Human and Peoples' Rights Special Mechanisms

• The Working Groups on Economic, Social, and Cultural Rights, and on Death Penalty, Extra-Judicial, Summary, or Arbitrary Killings, and Enforced Disappearances in Africa should request and invitation from the Ethiopian government to visit and assess the human rights and humanitarian situation in Ethiopia.

Acknowledgments

This report was researched and written by a researcher in the Africa division. Open source and remote sensing research were provided by Carolina Jordá Álvarez, senior geospatial analyst and Gabi Ivens, head of open-source research in the Digital Investigations Lab. The report was reviewed and edited by Laetitia Bader, deputy Africa director, James Ross, legal and policy director, and Babatunde Olugboji, deputy program director, provided legal and programmatic review respectively.

Allan Ngari, Africa advocacy director; Philippe Dam, EU director for advocacy; Sarah Yager, Washington director; Lucy McKernan, deputy UN Geneva director; Yasmine Ahmed, UK director, Widad Franco, UN advocacy officer; Sam Dubberley, managing director of the Digital Investigations Lab; Matt McConnell, researcher in the Economic Justice and Rights Division; Elin Martinez, senior researcher in the Children's Rights Division; Betty Kabari, researcher in the Women's Rights Division; and Mark Hiznay, associate director in the Crisis, Conflict, and Arms Division provided additional reviews.

The report was prepared for publication by Africa associate Eunice Njagi; publications officer, Travis Carr; and senior administrative manager, Fitzroy Hepkins.

Human Rights Watch would like to thank the various people in Ethiopia and elsewhere, including health care providers, who, shared their experiences with us and made this report possible, despite concerns of possible government reprisals. In deference to their concerns, we have honored their requests for anonymity, but their contributions made this report possible.

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